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Injections: Drugs A-L Policy                                                                                  1
This section outlines policy related to billing for injection services, listed in alphabetical order by generic
drug name or drug type. For general billing policy information regarding injections services, refer to the
Injections: An Overview section in this manual. Additional policy information for injection services can be
found in the Injections: Drugs M–Z, Injections: Hydration and Immunizations sections in this manual.


17a-Hydroxyprogesterone              Policy information about 17a-hydroxyprogesterone, billed with HCPCS
                                     code J3490 (unclassified drug) is located under “Preventing Preterm
                                     Births: 17a-Hydroxyprogesterone Injections” in the Pregnancy: Early
                                     Care and Diagnostic Services section of the appropriate Part 2
                                     manual.



                         ®
Abatacept (Orencia )                 Abatacept (HCPCS code J0129) is used for the treatment of
                                     moderately to severely active rheumatoid arthritis.


TAR Required                         Abatacept treatments require a Treatment Authorization Request
                                     (TAR) and the request may be for up to six months of treatment.
                                     There must be documentation that the patient has had an inadequate
                                     response after treatment with the following:
                                          One or more non-biologic Disease-Modifying Anti-Rheumatic
                                           Drugs (DMARDs) or
                                          At least one of the tumor necrosis factor (TNF) antagonists
                                           (infliximab, etanercept or adalimumab) or the interleukin-1
                                           receptor antagonist anakinra.



Dosage                               Abatacept is initially administered as a 30-minute intravenous infusion.
                                     Following the first infusion, abatacept should be given at two and four
                                     weeks, then every four weeks thereafter. Either of the following dosing
                                     schedules may be used:
                                     1. Abatacept, 10 mg/kg with a maximum dose of 1,000 mg, or
                                     2. According to body weight:
                                           Body weight of patient        Dose
                                           <60 kg                        500 mg
                                           60 to 100 kg                  750 mg
                                           >100 kg                       1,000 mg

                                     Dose = 750 mg per administration on days 0, 14, 28, and every
                                     28 days thereafter for a total of six months. This is eight (8) doses
                                     for six months.
                                     8 doses X 750 mg = 6,000 mg.
                                     6,000 mg/10 mg/unit = 600 units requested on the TAR




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Medical Considerations              Providers should consider the following when administering
                                    abatacept:
                                        It should not be used concurrently with TNF antagonists
                                         (infliximab, etanercept, adalimumab), the interleukin-1 receptor
                                         antagonist anakinra or rituximab.
                                        It may be given as a monotherapy or with a non-biologic
                                         DMARD.
                                        It is a pregnancy category C drug.
                                        A minimum of three months should occur between the
                                         administration of abatacept and the patient receiving a live virus
                                         vaccine.
                                        Patients with chronic obstructive pulmonary disease (COPD)
                                         may develop adverse reactions to abatacept, including COPD
                                         exacerbation.


Billing                            HCPCS code J0129 (injection, abatacept, 10 mg);
                                   one (1) unit = 10 mg



AbobotulinumtoxinA                 AbobotulinumtoxinA (DYSPORT) is reimbursable for the treatment of
(DYSPORT)                          any of the following:

                                        Adults with cervical dystonia
                                        Achalasia (see following “Authorization” information)

                                   The botulinum toxins are a family of neurotoxins produced by various
                                   toxigenic strains of the gram-positive anaerobic bacterium Clostridium
                                   botulinum and are comprised of seven antigenically distinct serotypes
                                   (A to G). All botulinum neurotoxin serotypes produce their clinical
                                   effect of flaccid paralysis by blocking the release of acetylcholine from
                                   nerve endings.

                                   Three botulinum toxin products have been approved by the U.S. Food
                                   and Drug Administration (FDA).

                                   Two botulinum toxin serotype A products:

                                        AbobotulinumtoxinA (DYSPORT)
                                        OnabotulinumtoxinA (BOTOX)

                                   One botulinum toxin serotype B product:

                                        RimabotulinumtoxinB (Myobloc)




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                                   A significant difference within botulinum toxin type A serotypes is that
                                   the units are not interchangeable between the two FDA-approved
                                   products as there is no common international standard methodology
                                   for assaying units within the botulinum toxin serotypes. Therefore one
                                   unit of abobotulinumtoxinA is not equivalent to one unit of
                                   onabotulinumtoxinA. Similarly the units of one botulinum toxin
                                   serotype cannot be converted into units of any other botulinum toxin
                                   serotype as there is no common international standard methodology
                                   for assaying units among the different botulinum toxin serotypes.
                                   Consequently neither the units of abobotulinumtoxinA nor
                                   onabotulinumtoxinA are interchangeable with rimabotulinumtoxinB.
                                   The dosing of any botulinum toxin product must be individualized to
                                   each specific patient based upon many factors including, but not
                                   limited to, size of the muscles to be injected, the number of muscles to
                                   be injected, body weight, the condition being treated, expected patient
                                   response, and general health of the patient. Standard doses do not
                                   exist.


Authorization                      Medical necessity must be established and an approved Treatment
                                   Authorization Request (TAR) is required for reimbursement.

                                   If the request is for the treatment of achalasia, the TAR must
                                   document any of the following:

                                          Failed pneumatic dilation or myotomy
                                          Poor surgical candidate
                                          High risk for complications such as perforation
                                          History of hiatal hernia or epiphrenic diverticulum
                                          History of perforation


Dosing                             The initial dose of abobotulinumtoxinA is 500 units given
                                   intramuscularly as a divided dose among the affected muscles.
                                   Re-treatment is based on return of clinical symptoms with doses
                                   administered between 250 and 1,000 units to optimize clinical benefit.
                                   Re-treatment should not occur in intervals of less than 12 weeks.


Billing                            HCPCS Code
                                   J0586 Injection, abobotulinumtoxinA, 5 units
                                   One (1) unit = 5 units of abobotulinumtoxinA

                                   Due to the short half life of abobotulinumtoxinA, Medi-Cal will
                                   reimburse the unused portion of the drug only when vials are not split
                                   between patients. Scheduling of more than one patient is encouraged
                                   to prevent wastage of abobotulinumtoxinA. If a vial is split between
                                   two or more patients, the billing must be for the exact amount of drug
                                   administered to each individual patient.




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Acyclovir                          Acyclovir 5 mg (HCPCS injection code J0133) is reimbursable up to a
                                   maximum of 300 units.



Agalsidase Beta (Fabrazyme)        For detailed billing policy information about agalsidase beta, refer to
                                   the “Enzyme Replacement Drugs” topic in this manual section.



Algucosidase Alfa                  For detailed billing policy information about algucosidase alfa, refer to
(Lumizyme, Myozyme)                the “Enzyme Replacement Drugs” topic in this manual section.



Alteplase                          When intravenous thrombolytic agents are used in Acute Myocardial
          ®       ®
(Activase /Cathflo )               Infarction (AMI) cases, Medi-Cal only reimburses the cost of the
                                   agents. Alteplase (tissue plasminogen activator) is a commonly used
                                   agent in AMI cases.

                                   Streptokinase has been in use longer than alteplase and is less costly.
                                   In compliance with Medi-Cal regulations (California Code of
                                   Regulations, Title 22, 51003 [f]) limiting authorization to the “lowest
                                   cost item or service covered by the program that meets the patient’s
                                   medical needs,” reimbursement is usually limited to streptokinase
                                   (HCPCS injection code X6920).


Billing                            If alteplase (CPT-4 codes 96372 and 96379) is used, a statement
                                   must be included on or with the claim form indicating the medical
                                   necessity for using alteplase (for example, known allergy or recent
                                   exposure to streptokinase; unstable hypotension; early catheterization
                                   or surgery anticipated; or thrombolysis initiated four to six hours after
                                   AMI). In addition, an invoice must be attached showing the actual cost
                                   of alteplase used on that occasion.


Place of Service Restrictions      Alteplase use is separately reimbursable when treatment is initiated in
                                   an organized outpatient clinic or physician’s office prior to hospital
                                   admittance and the appropriate code is used. However, treatment
                                   initiated in a hospital emergency room is not separately reimbursable
                                   as it is included in the hospital reimbursement, regardless of whether
                                   the hospital is a contract or non-contract hospital.



                            ™
Anidulafungin (Eraxis )            Anidulafungin, 1 mg (HCPCS code J0348) must be billed with
                                   ICD-9-CM codes 112 – 112.9. The daily maximum dosage is 200 mg.




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Antigens for                       CPT-4 code 95115 or 95199 must be used for allergy desensitization.
Allergy Desensitization            Antigens must be billed with HCPCS code X7708; antigens billed with
                                   CPT-4 code 99070 (unlisted medical supplies) will be denied. Claims
                                   for hymenoptera venom antigen must be billed with code X7710 and
                                   must be accompanied by a copy of the invoice.



                          ®
Aripiprazole (Abilify )            HCPCS code J0400 (aripiprazole, intramuscular, 0.25 mg) is covered
                                   for the treatment of schizophrenia/episodic mood disorders. An
                                   ICD-9-CM diagnosis code within the range of 295.0 – 296.99 is
                                   required. The maximum daily dosage is 30 mg. Claims billed for
                                   quantities exceeding the above daily limitation require appropriate
                                   documentation for payment.



Baclofen                           HCPCS Level III code X7108 (baclofen injection, 10 mg) is
                                   reimbursable for intrathecal baclofen used for the treatment of
                                   spasticity in patients with spinal cord injury, multiple sclerosis or
                                   cerebral-origin spasticity (cerebral palsy or severe brain injury due to
                                   trauma, stroke or anoxia). This code is reimbursable only when billed
                                   in conjunction with HCPCS Level II code E0783 (infusion pump
                                   system, implantable, programmable [includes all components, e.g.,
                                   pump, catheter, connectors, etc.]).

                                   Authorization is required for codes X7108 and E0783, as well as for
                                   the hospitalization related to pump implantation. Recipients must meet
                                   all of the following conditions:
                                        Severe spasticity resulting from spinal cord trauma or multiple
                                         sclerosis that is refractory to conventional oral antispastic
                                         medication at maximum doses, or with intolerable side effects
                                         from medication; or, cerebral-origin spasticity; and
                                        Prior medical consequences of spasticity (for example,
                                         decubitus ulcers, spasticity-induced skeletal fractures,
                                         contractures, poor urinary management); and
                                        Failure of physical therapy to relieve spasticity symptoms; and
                                        A positive test injection by lumbar puncture or by placement of a
                                         temporary intrathecal catheter (during a 23-hour admission),
                                         with no response to placebo; and
                                        No contraindications (for example, pregnancy, history of stroke,
                                         impaired renal function, or severe hepatic or gastrointestinal
                                         disease).

                                   Note: It is not necessary for recipients with cerebral-origin spasticity to
                                         receive oral baclofen before receiving intrathecal baclofen.




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Test Injection                     The test injection of baclofen that precedes pump implantation may be
                                   billed without authorization using CPT-4 code 62311 (injection, single
                                   [not via indwelling catheter], not including neurolytic substances, with
                                   or without contrast [for either localization or epidurography], of
                                   diagnostic or therapeutic substance[s] [including anesthetic,
                                   antispasmodic, opioid, steroid, other solution], epidural or
                                   subarachnoid; lumbar, sacral [caudal]).


Pump Implantation                  The pump implantation procedure may be billed without authorization
                                   using CPT-4 codes 62350 and 62360, 62361 or 62362 (catheter and
                                   reservoir/pump implantation).


Refilling and Maintenance          Outpatient refilling and maintenance of the implantable pump or
                                   reservoir may be billed without authorization using CPT-4 code
                                   96522 (refilling and maintenance of implantable pump or reservoir).




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Betamethasone                      Betamethasone acetate and betamethasone sodium phosphate
(Celestone Soluspan)               (Celestone Soluspan) is reimbursable up to two units when billed by
                                   the same provider, for the same recipient and date of service


Billing                            HCPCS code J0702 (injection, betamethasone acetate 3 mg and
                                   betamethasone sodium phosphate 3 mg).

                                   One (1) unit = 6 mg of betamethasone (3 mg each of the acetate and
                                   sodium phosphate salts)



                             ®
Bevacizumab (Avastin )             Policy for intravitreal bevacizumub (HCPCS code J9035) is located in
                                   the Ophthalmology sections of the appropriate Part 2 manual.



C1 Esterase Inhibitor (Cinryze)    C1 esterase inhibitor is indicated for the routine prophylaxis against
                                   angioedema attacks in patients with hereditary angioedema.


Dosage                             Maximum dosage is 3000 units (quantity of 300). Claims billed for
                                   greater quantities require documentation that patient’s weight exceeds
                                   150 kg. Limited to patients 12 years of age and older.


Diagnosis Restrictions             Restricted to ICD-9-CM diagnosis code 277.6.


Billing                            HCPCS code J0598 (injection, C1 esterase inhibitor [human], 10 units)
                                   One unit = 10 units



Calcitriol                         Calcitriol is indicated in the management of hypocalcemia in patients
                                   undergoing chronic renal dialysis. It has been shown to significantly
                                   reduce elevated parathyroid hormone levels. The reduction of
                                   parathyroid hormone has been shown to result in an improvement in
                                   renal osteodystrophy.

Billing                            HCPCS code J0636 (injection, calcitriol, 0.1 mcg)




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Cefotaxime                         Cefotaxime sodium is a broad spectrum cephalosporin antibiotic
                                   for treating serious infections caused by susceptible organisms.


Injection Codes                    The following injection codes are used for billing this drug.

                                       HCPCS
                                       Code               Dosage
                                       X7025              0.5 Gm
                                       X7026              1.0 Gm
                                       X7027              2.0 Gm



Drug Limitations                   Claims for cefotaxime sodium are reimbursable up to a maximum
                                   dosage of 12 grams. Quantities billed in excess of 12 grams will be
                                   reduced to this limit. To receive additional reimbursement when billing
                                   for a quantity in excess of 12 grams, resubmit the claim with a Claims
                                   Inquiry Form (CIF) and justification for the additional dosage.



Ceftriaxone Sodium                 Ceftriaxone sodium is billed with the following injection code:
                                       HCPCS Code         Description
                                       J0696              250 mg vial
                                   Ceftriaxone sodium is a parenteral cephalosporin antibiotic and is
                                   particularly effective in the treatment of penicillin-resistant gonorrhea
                                   and severe multiple-resistant gram-negative rod infections. Its long
                                   half-life (six to nine hours) permits non-institutional treatment of severe
                                   infections that would otherwise require prolonged inpatient care.




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Certolizumab Pegol (Cimzia)        Certolizumab pegol is a tumor necrosis factor blocker. It is a
                                   recombinant humanized antibody Fab fragment, with specificity for
                                   human tumor necrosis factor alfa conjugated to an approximately 40
                                   kDa polyethylene glycol. It specifically neutralizes tumor necrosis
                                   factor alfa.


Indications                        Certolizumab pegol is indicated for:

                                        Reducing the signs and symptoms of Crohn’s Disease and
                                         maintaining clinical response in adult patients with moderately to
                                         severely active disease who have had an inadequate response
                                         to conventional therapy.

                                         Certolizumab pegol is not indicated for the treatment of (1)
                                         enterocutaneous or rectovaginal fistulas or (2) maintaining
                                         fistula closure.

                                        The treatment of adults with moderately to severely active
                                         rheumatoid arthritis


Dosage                             Crohn’s Disease:
                                       The recommended initial dose is 400 mg subcutaneously and at
                                         weeks two and four, and in patients who achieve a clinical
                                         response, the recommended maintenance regimen is 400 mg
                                         subcutaneously every four weeks.

                                   Rheumatoid Arthritis:
                                       The recommended dose is 400 mg subcutaneously and at
                                        weeks two and four, followed by 200 mg every other week. For
                                        maintenance dosing 400 mg every four weeks may be
                                        considered.


TAR Requirements                   Reimbursement for certolizumab pegol requires TAR approval.


Billing                            HCPCS code J0718, certolizumab pegol, 1 mg



                       ®
Cidofovir (Vistide )               Cidofovir is an anti-viral agent that suppresses cytomegalovirus (CMV)
                                   replication by selective inhibition of CMV DNA polymerase. Cidofovir
                                   is reimbursable for the treatment of CMV retinitis in patients with AIDS
                                   and when billed with HCPCS code X7434 (Cidofovir, 375 mg/5 ml vial).




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Dosage                             Cidofovir must be diluted in 100 ml of 0.9 percent (normal) saline prior
                                   to administration. The drug is administered at an induction dose of
                                   5 mg/kg body weight as an intravenous infusion at a constant rate
                                   over one hour, given once weekly for two consecutive weeks. The
                                   recommended maintenance dose is 5 mg/kg body weight administered
                                   once every two weeks.


Required Codes                     Code X7434 must be billed with chorioretinitis (ICD-9-CM codes
                                   363.00 – 363.35) as the primary or secondary diagnosis.


Infusion Administration            CPT-4 codes 96365 and 96366 (intravenous infusion, for therapy,
                                   prophylaxis, or diagnosis) are reimbursable in conjunction with
                                   cidofovir, as well as up to two liters of 0.9 percent (normal) saline, for
                                   the pre- and post-hydration needed with this drug.



Collagenase Clostridium            Collagenases are proteinases that hydrolyze collagen in its native helical
Histolyticum (Xiaflex)             conformation under physiological conditions, resulting in lysis of collagen
                                   deposits. Injection of collagenase clostridium histolyticum into a Dupuytren’s
                                   cord, which is comprised mostly of collagen, may result in enzymatic
                                   disruption of the cord. Purified collagenase clostridium histolyticum consists
                                   of collagenase AUX-I and collagenase AUX-II both of which are isolated and
                                   purified from the fermentation of Clostridium histolyticum bacteria


Indications                        Collagenase clostridium histolyticum is indicated for the treatment of adult
                                   patients aged 18 years and older with Dupuytren’s contracture with a
                                   palpable cord.

                                   Collagenase clostridium histolyticum should be administered by a healthcare
                                   provider experienced in injection procedures of the hand and in the
                                   treatment of Dupuytren’s contracture.


Required Codes                     ICD-9-CM 728.6


Dosage                             The usual dose is 0.58 mg, injected into a palpable Dupuytren’s cord with a
                                   contracture followed 24 hours later by a finger extension procedure if a
                                   contracture persists.

                                   Injections and finger extension procedures may be administered up to three
                                   times per cord at approximately four-week intervals.


Billing                            HCPCS code J0775 (injection, collagenase, clostridium histolyticum, 0.01
                                   mg)




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Corticorelin Ovine                 Corticorelin Ovine Triflutate, 1 mg, (HCPCS injection code J0795) is
                   ®
Triflutate (Acthrel )              reimbursable, with authorization, for patients with ACTH dependent
                                   Cushing’s Syndrome. ICD-9-CM diagnosis code 255.0 must be
                                   included on the TAR.



Corticosteroids                    Reimbursement for injectable corticosteroids in the treatment of acute
                                   exacerbations of multiple sclerosis is allowed in conformance with
                                   Medicare guidelines. The following drugs are reimbursable on claims
                                   with a diagnosis of acute exacerbation or flare-up of multiple sclerosis.

                                   Aristocort                   Depo-Medrol             Kenalog
                                   Celestone                    Hydrocortisone          Prednisolone
                                   Soluspan
                                   Decadron
                                   Phosphate




Cosyntropin                        Cosyntropin is intended for use as a diagnostic agent in the screening
                                   of patients presumed to have adrenocortical insufficiency.


Billing Codes                      The following HCPCS codes are used to bill cosyntropin:
                                       HCPCS
                                       Code              Description
                                       J0833             Injection, cosyntropin, not otherwise specified,
                                                         0.25 mg
                                                         One unit = 0.25 mg
                                       J0834             Injection, cosyntropin (Cortrosyn), 0.25 mg)
                                                         One unit = 0.25 mg

                                   Codes J0833 and J0834 cannot be reported on the same claim.



                           ®
Daptomycin (Cubicin )              Daptomycin, 1 mg (HCPCS code J0878) has a maximum dose of
                                   6 mg/kg/day in one daily dose. The maximum dose for this antibiotic is
                                   816 mg/day without documentation, unless the rendering provider
                                   documents that the patient weighs more than 137 kg




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                             ®
Darbepoetin (Aranesp )             Darbepoetin alfa, 1 mcg injection is reimbursable for the
Codes J0881 and J0882              treatment of anemia caused by chronic renal disease (HCPCS code
                                   J0882) and for anemia due to treatment with chemotherapeutic agents
                                   for cancer (HCPCS code J0881).


Required Codes                     Darbepoetin alfa, 1 mcg - ESRD use (code J0882) by subcutaneous
                                   injection is reimbursable when billed in conjunction with the following

                                   ICD-9-CM codes.
                                       585.1 – 585.9 (chronic renal failure) or
                                       586 (renal failure, unspecified) or
                                       V56.0 – V56.8 (encounter for dialysis) and
                                       285.21 (anemia in end-stage renal disease)

                                   When using code J0881 (non-ESRD use), bill with the following
                                   ICD-9-CM codes:

                                          140.0 – 239.9 (neoplasms) or
                                          V58.11 or V58.12 (chemotherapy) and
                                          285.22 (anemia in neoplastic disease) or 285.29
                                          285.3 – 285.39 (antineoplastic chemotherapy induced anemia)


Documentation Requirements         Providers must document in the Remarks field (Box 80)/Reserved for
                                   Local Use field (Box 19) or on an attachment to the claim all of the
                                   following:
                                        The patient’s body weight in kilograms
                                        A recent hematocrit/hemoglobin within the last three months
                                         from the commencement date of treatment of darbepoetin
                                        The dosage of darbepoetin given in mcg

                                   If the recipient is receiving darbepoetin for anemia due to
                                   chemotherapy for cancer, documentation of the chemotherapy
                                   regimen that has been or will be administered must be included with
                                   the claim.

                                   If the recipient is not receiving chemotherapy at the time of treatment
                                   with darbepoetin, providers may be reimbursed if documentation is
                                   attached to the claim stating the recipient is not currently on
                                   chemotherapy, or that chemotherapy is not currently warranted.




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                                   When the dosage of darbepoetin alfa 1 mcg injection (HCPCS codes
                                   J0881 and J0882) exceeds 400 mcg, medical justification must be
                                   attached documenting the necessity for exceeding 400 mcg. If
                                   medical justification is not attached to the claim form to justify billing
                                   for more than 400 mcg, the claim will be cut back to 400 mcg. If the
                                   recipient was given more than 400 mcg, but the documentation was
                                   not included with the claim, it is necessary to resubmit a Claims
                                   Inquiry Form (CIF) adjustment, including a claim for the full dosage,
                                   with attached medical justification.


Dosage                             Darbepoetin has a maximum allowed dosage and frequency as
                                   follows:
                                       Dosage        Duration
                                       100 mcg       per 1 week
                                       200 mcg       per 2 weeks
                                       300 mcg       per 3 weeks
                                       400 mcg       per 4 weeks

                                   For anemia due to chronic renal failure, the recommended starting
                                   dose is 0.45 mcg/kg I.V. or subcutaneous once a week. The dosage
                                   of darbepoetin should be increased every two to four weeks until the
                                   target hematocrit/hemoglobin is achieved.


Exceptions                         The allowed dosage and frequency may be overridden under the
                                   following conditions, with supporting documentation attached to the
                                   claim:
                                        The patient has failed to meet a target hematocrit of 36 percent
                                         or a target hemoglobin of 12g/dl when given a dosage of
                                         darbepoetin according to the preceding regimen.
                                        There is medical justification of a condition that requires a target
                                         hematocrit/hemoglobin that exceeds 36 percent/12g/dl but not
                                         greater than a hematocrit/hemoglobin of 40.5 percent/13.5g/dl.
                                         This may include but is not limited to cardiovascular and
                                         pulmonary disease.
                                        When the hematocrit/hemoglobin exceeds 36 percent/12g/dl,
                                         and a request for a higher target is not made, the provider must
                                         document the dosage of darbepoetin was reduced in response
                                         to the exceeded target level.
                                        Whenever the maximum dose of darbepoetin is exceeded, iron
                                         deficiency anemia should be evaluated through iron studies
                                         and/or ferritin or through undergoing or having completed
                                         treatment, with documentation showing one of the following:
                                         – Iron deficient anemia has been excluded
                                         – Patient has completed treatment for iron deficiency anemiia
                                         – Patient is currently receiving therapeutic doses of oral
                                           parenteral iron
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Denosumab (Prolia, XGEVA)          Denosumab is a human IgG2 monoclonal antibody that binds to
                                   RANKL (receptor activator of nuclear factor kappa-B ligand), a
                                   transmembrane or soluble protein essential for the formation, function
                                   and survival of osteoclasts, the cells responsible for bone resorption.
                                   Denosumab prevents RANKL from activating its receptor, RANK,
                                   which is expressed on the surface of osteoclasts and their precursors.
                                   Prevention of the RANKL/RANK interaction inhibits osteoclast
                                   formation, function and survival, thereby decreasing bone resorption
                                   and increasing bone mass and strength in both cortical and trabecular
                                   bone. In addition, increased osteoclast activity, stimulated by RANKL,
                                   is a mediator of bone pathology in solid tumors with osseous
                                   metastases.


Indications                        Denosumab is indicated for the:

                                              Treatment of postmenopausal women with osteoporosis at
                                               high risk for fracture
                                              Prevention of skeletal related events in patients with bone
                                               metastases from solid tumors


Dosage                             For treatment of postmenopausal women with osteoporosis at high
                                   risk for fracture, the recommended dose is 60 mg subcutaneously
                                   every six months. Recipients should receive 1,000 mg of calcium
                                   daily and at least 400 IU of vitamin D daily.

                                   For prevention of skeletal related events in patients with bone
                                   metastases from solid tumors, the recommended dose is 120 mg
                                   subcutaneously every four weeks in the upper arm, upper thigh or
                                   abdomen.


Diagnosis Restrictions             When using denosumab (Prolia) for the treatment of postmenopausal
                                   women with osteoporosis at high risk for fractures, only one diagnosis
                                   code in the range of 733.0 – 733.09 is required for reimbursement.

                                   When using denosumab (XGEVA) for the treatment of bone
                                   metastases from solid tumors, providers must supply a primary and a
                                   secondary diagnosis code. Both codes are required for
                                   reimbursement:
                                               Primary code: 198.5
                                               Secondary code: the code which signifies the solid tumor
                                                causing the metastases when treating osteoporosis


Billing                            HCPCS code C9272 (Injection, denosumab, 1 mg)
                                   The claim must include the NDC number in order for the claim to be
                                   appropriately paid:
                                               Denosumab (Prolia) NDC 55513-0710-01 single use syringe
                                               Denosumab (XGEVA) NDC 55513-0730-01

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Dexamethasone Intravitreal             Policy for intravitreal dexamethasone (HCPCS code C9256) is located
Implant (Ozurdex)                      in the Ophthalmology sections of the appropriate Part 2 manual.



                           ®
Dolasetron (Anzemet )                  Providers may be reimbursed for dolasetron mesylate when used for
                                       either of the following indications:
                                            The prevention of nausea and vomiting associated with initial
                                             and repeat courses of emetogenic cancer chemotherapy
                                            The prevention or treatment of postoperative nausea and/or
                                             vomiting


Dosage                                 The usual dose is 1.8 mg per kg of body weight up to 100 mg.


Billing                                HCPCS code J1260 (injection, dolasetron mesylate, 10 mg)
                                       1 unit = 10 mg


Physician Certification                Claims billing for infusion therapy must include an attached
Required                               certification affirming that the physician performed the infusion therapy
                                       or was in attendance and supervising throughout the therapy. Proper
                                       certification on these claims will prevent denials.



                          ™
Doripenem (Doribax )                   Doripenem, 10 mg (HCPCS code J1267) has a usual dosage of
                                       500 mg every eight hours with a maximum daily dosage of 1,500 mg.
                                       For quantities exceeding the daily limitation, appropriate
                                       documentation is required.



                                   ®
Doxercalciferol (Hectorol )            Doxercalciferol is reimbursable for the treatment of secondary
                                       hyperparathyroidism in patients with chronic kidney disease on
                                       dialysis.


Dosage                                 The recommended initial dose of doxercalciferol is 4 mcg administered
                                       intravenously as a bolus dose three times weekly at the end of dialysis.
                                       The maximum dosage should not exceed 18 mcg weekly.

Billing                                HCPCS code J1270 (injection, doxercalciferol, 1 mcg)
                                       1 unit = 1 mcg




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Enzyme Replacement Drugs           In the early 1960s, the first lysosomal storage disease was identified.
                                   Since then over 40 such diseases have been reported. The common
                                   feature is that enzyme deficiency leads to accumulation of undegraded
                                   macromolecules and lysosomal engorgement, resulting in organ
                                   dysfunction. Enzyme replacement drugs have been developed for
                                   many of these diseases. The following enzyme replacement drugs are
                                   benefits of the Medi-Cal program:

                                          Agalsidase Beta (Fabrazyme)
                                          Alglucosidase Alfa (Myozyme)
                                          Galsulfase (Naglazyme)
                                          Idursulfase (Eleprase)
                                          Imiglucerase (Cerezyme)
                                          Laronidase (Aldurazyme)
                                          Velaglucerase alfa

                                   Authorization requirements for enzyme replacement drugs are
                                   described below. On the following pages the drugs are listed
                                   individually with information about their usage, dosage and billing
                                   requirements.

                                   Note: Pharmacy providers of enzyme replacement therapy drugs may
                                         bill Medi-Cal directly using the NDC for the medication. This is
                                         a special Assignment of Benefit (AOB) exception to the DHCS
                                         policy restricting the reimbursement of all physician
                                         administered drugs to physicians and clinics. Pharmacy
                                         providers must submit TARs to the Los Angeles Medi-Cal Field
                                         Office, with the supporting documentation listed below. In
                                         addition the pharmacy must include on the TAR the name of the
                                         physician to whom the medication will be released, or the name
                                         of the authorized representative specifically identified by the
                                         prescribing physician to receive the medication on his/her
                                         behalf. Pharmacies may not release the medication to anyone
                                         other than the prescribing physician without documented
                                         authorization from the prescribing physician identifying the
                                         specific agent authorized to receive the medication.




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Authorization                      An approved TAR is required for reimbursement for each of these
                                   drugs. The TAR must be submitted to the Los Angeles Medi-Cal Field
                                   Office.

                                   For the initial TAR the following supporting documentation must be
                                   submitted:

                                        Subjective findings (complaints)
                                        Objective findings (exams, lab results)
                                          Enzyme levels or other laboratory testing
                                          DNA mutation analysis
                                          Medical history
                                          Physical examination
                                        Complications (for example, bony changes or kidney failure)
                                        Quality of life issues (for example, severe, unremitting pain or
                                         extreme fatigue)
                                        Identified licensed practitioner who will administer infusion
                                         therapy, coordinate care, and their
                                          Plan: Include the treatment plan including the genetic
                                                 evaluation and counseling information for the recipient
                                                 and family members.
                                          Goal: Include specific information about the desired
                                                 outcome; for example, to slow the progression of the
                                                 disease, to allow regular attendance at work or school
                                                 or to significantly improve the quality of life.


                                   Initial TAR approval may be for up to six months. Renewal TARs must
                                   include follow-up information such as any significant changes in
                                   physical findings, laboratory parameters, symptoms and/or quality of
                                   life.


Agalsidase Beta (Fabrazyme)        Fabry disease is an X-linked genetic disorder of glycosphingolipid
                                   metabolism. Deficiency of the lysosomal enzyme
                                   alpha-galactosidase-A leads to progressive accumulation of
                                   glycosphingolipids, predominantly GL-3, in many body tissues, starting
                                   early in life and continuing over decades. Agalsidase beta is a
                                   recombinant form of the enzyme alpha-galactosidase-A, which is
                                   required for the hydrolysis of GL-3 and other glycosphingolipids. In
                                   clinical trials of limited duration, agalsidase been noted to reduce
                                   tissue inclusions of GL-3. It is believed that long-term enzyme
                                   replacement may reduce clinical manifestations of renal failure,
                                   cardiomyopathy, and stroke.

                                   Indications
                                   For use in patients with Fabry disease.




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                                   Authorization
                                   The TAR must include a diagnosis of Fabry disease. For other TAR
                                   requirements, see “Authorization” near the beginning of the “Enzyme
                                   Replacement Drugs” topic.

                                   Dosage
                                   The recommended dose is 1 mg/kg every two weeks.

                                   Billing
                                   HCPCS code J0180 (injection, agalsidase beta, 1 mg)


Alglucosidase Alfa                 Pompe disease is an inherited disorder of glycogen
(Lumizyme, Myozyme)                metabolism caused by the absence or marked deficiency of the
                                   enzyme lysosomal acid maltase (alfa glucosidase). In the
                                   infantile-onset form, Pompe disease results in intralysosomal
                                   accumulation of glycogen in various tissues, particularly cardiac and
                                   skeletal muscles, and hepatic tissues, leading to the development of
                                   cardiomyopathy, progressive muscle weakness, and impairment of
                                   respiratory function. In the juvenile and adult-onset forms,
                                   intralysosomal accumulation of glycogen is limited primarily to skeletal
                                   muscle, resulting in progressive muscle weakness. Death in all forms
                                   is usually related to respiratory failure. Alglucosidase alfa provides an
                                   exogenous source of the enzyme lysosomal acid maltase
                                   Indications
                                   Lumizyme is used for treatment of recipients 8 years of age and older
                                      with late (non-infantile) onset Pompe disease.
                                   Myozyme is used for treatment of recipients younger than 8 years of
                                      age with infantile onset Pompe disease.

                                   Authorization
                                   The TAR must include a diagnosis of Pompe disease. For other TAR
                                   requirements, see “Authorizations” near the beginning of the “Enzyme
                                   Replacement Drugs” topic.

                                   Dosage
                                   The recommended dose is 20 mg/kg every two weeks.
                                   Billing
                                   HCPCS code J0220 (injection, alglucosidase alfa, 10 mg)
                                   The correct National Drug Code (NDC) must be included on claims,
                                   as follows:
                                      Lumizyme (50 mg/20 ml vial): NDC code 58468-0160-1
                                      Myozyme (50 mg/20 ml vial): NDC code 58468-0150-1




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Galsulfase (Naglazyme)             Mucopolysaccharidosis VI (Maroteaux-Lamy syndrome)
                                   is characterized by the absence or marked reduction in
                                   N–acetylgalactosamine-4-sulfatase. The sulfatase deficiency results
                                   in accumulation of partially degraded glycosaminoglycans, dermatan
                                   sulfate, and chondroitin 4-sulfate. This accumulation leads to
                                   widespread cellular, tissue, and organ dysfunction. Inheritance is
                                   autosomal recessive. Galsulfase is intended to provide an exogenous
                                   enzyme that will be taken up into lysosomes and increase the
                                   catabolism of glycosaminoglycans.
                                   Indications
                                   For use in patients with Mucopolysaccharidosis VI
                                   Authorization
                                   The TAR must include a diagnosis of Mucopolysaccharidosis VI. For
                                   additional details regarding authorization for this drug, see the
                                   “Enzyme Replacement Drugs” topic in this manual section.

                                   Dosage
                                   The recommended dose is 1 mg/kg once a week.

                                   Billing
                                   HCPCS code J1458 (injection, galsulfase, 1 mg)


Idursulfase (Eleprase)             Hunter syndrome (Mucopolysaccharidosis II, MPS II) is an X-linked
                                   recessive disease caused by insufficient levels of the lysosomal
                                   enzyme iduronate-2-sulfatase. This enzyme cleaves the terminal
                                   2-0-sulfate moieties from dermatan sulfate and heparan sulfate. Due
                                   to the missing or defective iduronate-2-sulfatase enzyme in patients
                                   with Hunter syndrome, dermatan sulfate and heparan sulfate
                                   progressively accumulate in the lysosomes of a variety of cells, leading
                                   to cellular engorgement, organomegaly, tissue destruction, and organ
                                   system dysfunction.

                                   Indications
                                   For use in patients with Hunter syndrome.

                                   Authorization
                                   The TAR must include a diagnosis of Hunter syndrome. For other
                                   TAR requirements, see “Authorizations” near the beginning of the
                                   “Enzyme Replacement Drugs” topic.

                                   Dosage
                                   The recommended dose is 0.5 mg/kg once a week.

                                   Billing
                                   HCPCS code J1743 (injection, idursulfase, 1 mg)




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Imiglucerase (Cerezyme)            Gaucher disease is classically categorized into three
                                   main types (I, II and III) and is characterized by a deficiency of
                                   beta-glucocerebrosidase activity, resulting in accumulation of
                                   glucocerebroside in tissue macrophages which become engorged and
                                   are typically found in the liver, spleen, and bone marrow and
                                   occasionally in lung, kidney, and intestine. Secondary hematologic
                                   sequelae include severe anemia and thrombocytopenia in addition to
                                   the characteristic progressive hepatosplenomegaly, skeletal
                                   complications, including osteonecrosis and osteopenia with secondary
                                   pathological fractures. Imiglucerase catalyzes the hydrolysis of
                                   glucocerebroside to glucose and ceramide. In clinical trials,
                                   imiglucerase improved anemia and thrombocytopenia, reduced spleen
                                   and liver size, and decreased cachexia.

                                   Indications
                                   For long-term enzyme replacement therapy for pediatric and adult
                                   patients with a confirmed diagnosis of Type 1 Gaucher disease that
                                   results in one or more of the following conditions:
                                            anemia
                                            thrombocytopenia
                                            bone disease
                                            hepatomegaly or splenomegaly

                                   Authorization
                                   The TAR must include a diagnosis of Type 1 Gaucher disease. For
                                   other TAR requirements, see “Authorizations” near the beginning of
                                   the “Enzyme Replacement Drugs” topic.

                                   Dosage
                                   Dosages range from 2.5 units/kg three times a week to 60 units/kg
                                   every two weeks. The dosage should be individualized to each
                                   patient.

                                   Billing
                                   HCPCS code J1786 (injection, imiglucerase, per unit)

                                   Claim Submission for Imiglucerase:
                                   When submitting a claim for the reimbursement of imiglucerase, enter
                                   a one (1) in the Days or Units column on the CMS-1500 claim form.




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Laronidase (Aldurazyme)            Mucopolysaccharidosis I (MPS I) is characterized by the deficiency of
                                   alpha-L-iduronidase, a lysosomal hydrolase which catalyzes the
                                   hydrolysis of terminal alpha-L-iduronic acid residues of dermatan
                                   sulfate and heparan sulfate. Reduced or absent alpha-L-iduronidase
                                   activity results in the accumulation of dermatan sulfate and heparan
                                   sulfate throughout the body and leads to widespread cellular, tissue,
                                   and organ dysfunction. MPS I includes Hurler, Hurler-Scheie, and
                                   Scheie syndromes that represent the spectrum of severity. The
                                   clinical phenotype covers a broad spectrum and patients with severe,
                                   intermediate, and mild features are classified as Hurler, Hurler-Scheie,
                                   and Scheie syndromes, respectively.

                                   Indications
                                   Laronidase is indicated for patients with Hurler and Hurler-Scheie
                                   forms of MPS I and for patients with the Scheie form who have
                                   moderate to severe symptoms. The risks and benefits of treating
                                   mildly affected patients with the Scheie form have not been
                                   established.

                                   Authorization
                                   The TAR must include a diagnosis of either Hurler and Hurler-Scheie
                                   forms of MPS I, or the Scheie form with moderate to severe
                                   symptoms. For other TAR requirements, see “Authorizations” near the
                                   beginning of the “Enzyme Replacement Drugs” topic.

                                   Dosage
                                   The recommended dose is .58 mg/kg once a week.

                                   Billing
                                   HCPCS code J1931 (injection, laronidase, 0.1 mg)


Velaglucerase Alfa                 Gaucher disease is classically categorized into three main
(VPRIV)                            types (I, II and III) and is characterized by a deficiency of
                                   beta-glucocerebrosidase activity, resulting in accumulation of
                                   glucocerebroside in tissue macrophages that become engorged and
                                   are typically found in the liver, spleen and bone marrow and
                                   occasionally in lung, kidney and intestine. Secondary hematologic
                                   sequelae include severe anemia and thrombocytopenia in addition to
                                   the characteristic progressive hepatosplenomegaly, skeletal
                                   complications, including osteonecrosis and osteopenia with secondary
                                   pathological fractures. Velaglucerase alfa catalyzes the hydrolysis of
                                   glucocerebroside to glucose and ceramide.

                                   Indications
                                   For use in patients 4 years of age or older with Type I Gaucher
                                   disease.

                                   Authorization
                                   The TAR must include a diagnosis of Type I Gaucher disease. For
                                   other TAR requirements, see “Authorization” near the beginning of the
                                   “Enzyme Replacement Drugs” topic.
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                                   Dosage
                                   The recommended dose is 60 units/kg every other week as a
                                   60-minute infusion.

                                   Billing
                                   HCPCS code J3385 (injection, velaglucerase alfa, 100 units)

                                   Claims must include an invoice showing the cost of the drug.



Epoetin Alfa                       The following HCPCS codes should be used when billing epoetin alfa:

                                       HCPCS Code         Description
                                       J0885              Epoetin alfa, for non-ESRD use, 1,000 units
                                       J0886              Epoetin alfa, for ESRD use, 1,000 units

                                   Note: These codes are used for billing Epogen and Procrit.


Code J0886                         HCPCS code J0886 is reimbursable only when used in the treatment
                                   of patients with anemia associated with end stage renal disease
                                   (ESRD) on dialysis. Dialysis facilities may bill for this drug in addition
                                   to their composite rate.


Required Codes                     Providers must bill claims for HCPCS code J0886 using ICD-9-CM
                                   diagnosis codes 585.6 (end stage renal disease) and 285.21 (anemia
                                   in chronic kidney disease) in the Diagnosis or Nature of Illness or
                                   Injury field (Box 21) or Box 67 of the claim.


Billing                            Claims billed with HCPCS code J0886 must include the following
                                   information either as an attachment to the claim or the information
                                   must be entered in the Remarks field (Box 80) on the UB-04 claim or
                                   in the Reserved for Local Use field (Box 19) on the CMS-1500 claim:

                                        Diagnosis of ESRD; and
                                        ICD-9-CM codes 585.6 (end stage renal disease) and 285.21
                                         (anemia in chronic kidney disease); and
                                        The patient’s body weight in kilograms; and
                                        The amount of epoetin alfa administered to the patient in
                                         units/kg; and either (a) or (b) below:
                                          (a) Three consecutive monthly hematocrit (Hct) and/or
                                          hemoglobin (Hgb) levels for a 90-day rolling average
                                          (b) The Hct and/or Hgb of the previous or current month




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                                   The Hct and/or Hgb target range for the rolling average for three
                                   consecutive months, or the previous month Hct and/or Hgb target
                                   range must be equal to or less than an Hct of 36 percent and/or an
                                   Hgb of 12g/dl. Because fluctuations to the target range may occur, the
                                   threshold for the Hct and/or Hgb will be set at a Hct level of 37.5
                                   percent and/or an Hgb of 12.5g/dl. If the threshold is exceeded,
                                   providers must include documentation with the claim that the dosage
                                   of epoetin alfa was reduced or held in response to the exceeded
                                   threshold.

                                   For patients who require a higher target range, the target range may
                                   be approved up to an Hct of 39 percent and/or an Hgb of 13 g/dl with
                                   medical justification, including but not limited to, ischemic heart
                                   disease and congestive heart failure. Because fluctuations to the
                                   higher target range may occur, the threshold Hct/Hgb will be 40.5
                                   percent/13.5g/dl. If the higher threshold level exceeds 40.5
                                   percent/13.5g/dl, providers must include documentation with the claim
                                   that the dosage of epoetin alfa was reduced or held in response to the
                                   exceeded threshold.
                                   Documentation of target/threshold requirements summary for J0886
                                   epoetin alfa:

                                    Target and threshold                    Medical necessity documentation
                                    Target:          Hct ≤36% and/or        None required
                                                     Hgb 12g/dl

                                    Threshold:       Hct ≤37.5% and/or      If the threshold was exceeded,
                                                     Hgb 12.5g/dl           documentation that the epoetin
                                                                            alfa dosage was reduced or held

                                    Target:          Hct 39% and/or Hgb     Medical justification for the higher
                                                     13g/dl                 target such as, but not limited to,
                                                                            ischemic heart disease or
                                                                            congestive heart failure


                                    Threshold:       Hct ≤40.5% and/or      In addition to medical justification,
                                                     Hgb 13.5g/dl           if the threshold was exceeded,
                                                                            documentation that the epoetin
                                                                            alfa dosage was reduced or held.




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                                   Note: When epoetin alfa is self-administered by the in-home dialysis
                                         patient, the provider must submit the following information
                                         either as an attachment to the claim or in the Remarks field
                                         (Box 80) on the UB-04 claim or in the Reserved for Local Use
                                         field (Box 19) on the CMS-1500 claim:

                                           A statement that the drug was provided to the recipient for
                                            self-administration.
                                           The date the supply was given to the recipient.
                                           The number of units administered per day and frequency of
                                            injections.


Code J0885                         HCPCS code J0885 (injection, epoetin alfa, [for non-ESRD use], 1000
                                   units) is reimbursable when used in the treatment of patients with
                                   anemia associated with one of the following medical conditions:

                                        Chronic renal failure (CRF), pre-ESRD, non-dialysis
                                        Antiretroviral therapy for HIV-infected patients
                                        Elective, noncardiac, nonvascular surgery when patient is
                                         unable or unwilling to donate autologous blood
                                        Chemotherapy for non-myeloid malignancies
                                        Myelodysplastic syndrome (MDS)


Required Codes                     When billing epoetin alfa for chronic kidney disease only, providers
(Chronic Kidney Disease)           must bill using the following ICD-9-CM diagnosis codes in the
                                   Diagnosis or Nature of Illness or Injury field (Box 21) or Box 67 of the
                                   claim:
                                        585.1 – 585.5 (chronic renal failure, stages I, II, III, IV and V),
                                         or 585.9 (chronic kidney disease, unspecified); and

                                        285.21 (anemia in chronic kidney disease)
                                   Note: J0885 cannot be billed with ICD-9-CM diagnosis code 585.6
                                         (end stage renal disease).


Billing                            Claims billed with HCPCS code J0885 must include the following
                                   information either as an attachment to the claim or the information
                                   must be entered in the Remarks field (Box 80) on the UB-04 claim or
                                   in the Reserved for Local Use field (Box 19) on the CMS-1500 claim:

                                        The patient’s medical condition, associated with anemia.
                                        The patient’s weight in kilograms.
                                        A hematocrit and/or hemoglobin level within the last three
                                         months including the date of the test.
                                        The amount of epoetin alfa administered in units/kg.

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                                   Because fluctuations to the target range may occur, the threshold for
                                   the Hct and/or Hgb will be initially set at an Hct of 37.5 percent, and/or
                                   an Hgb of 12.5 g/dl. If the threshold is exceeded, providers must
                                   include documentation with the claim that the dosage of epoetin alfa
                                   was reduced or held in response to exceeded thresholds.

                                   For patients who require a higher target range, the target range
                                   may be approved up to a Hct of 39 percent and/or a Hgb of 13 g/dl
                                   with medical justification, including but not limited to ischemic heart
                                   disease or congestive heart failure. Because fluctuations to the
                                   higher target range may occur, the threshold Hct/Hgb will be
                                   40.5 percent/13.5 g/dl. If the higher threshold exceeds
                                   40.5 percent/13.5 g/dl, providers must include documentation
                                   with the claim that the dosage of epoetin alfa was reduced or held in
                                   response to the exceeded threshold.

                                   Documentation of target/threshold requirements summary for J0885
                                   epoetin alfa:

                                    Target and threshold                    Medical necessity documentation
                                     Target:          Hct ≤36% and/or       None required
                                                      Hgb 12g/dl

                                    Threshold:        Hct ≤37.5% and/or     If the threshold was exceeded,
                                                      Hgb 12.5g/dl          documentation that the epoetin
                                                                            alfa dosage was reduced or held

                                     Target:          Hct 39% and/or Hgb    Medical justification for the
                                                      13g/dl                higher target such as, but not
                                                                            limited to, ischemic heart
                                                                            disease or congestive heart
                                                                            failure

                                     Threshold:       Hct ≤40.5% and/or     In addition to medical
                                                      Hgb 13.5g/dl          justification, if the threshold was
                                                                            exceeded, documentation that
                                                                            the epoetin alfa dosage was
                                                                            reduced or held



Documentation for Anemia           When billing epoetin alfa for the treatment of anemia related to
Related to Chemotherapy,           chemotherapy, myelodysplastic syndrome, or elective surgery,
Myelodysplastic Syndrome           each date of service must be billed on an individual claim line. The
and Elective Surgery               date of the surgery and the dose and schedule of epoetin alfa must be
                                   documented in the Remarks field (Box 80) on the UB-04 claim or in
                                   the Reserved for Local Use field (Box 19) on the CMS-1500 claim.
                                   Claims billed on a “from-through” basis will be denied.




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Documentation for                  For the treatment of anemia associated with anti-retroviral therapy
Anti-Retroviral Therapy            in HIV-infected patients, the following additional information must
                                   accompany the claim or be included in the Remarks field
                                   (Box 80)/Reserved for Local Use field (Box 19) of the claim:
                                        The patient’s current anti-retroviral drug regimen.
                                        The patient’s serum erythropoietin level. (This level should be
                                         less than or equal to 500 mU/ml).




Etonogestrel Implant               Refer to the Family Planning section in the appropriate Part 2
         ™
(Implanon )                        manual for billing instructions for etonogestrel contraceptive implant
                                   systems (HCPCS code J7307).




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Ferric Gluconate,                  Sodium ferric gluconate complex in sucrose, 62.5 mg injection
Sodium Complex in                  (HCPCS code X7496), is reimbursable when used to treat
                  ®
Sucrose (Ferrlecit )               recipients with iron deficiency anemia and for recipients undergoing
                                   long term hemodialysis and who are also receiving supplemental
                                   erythropoietin (EPO) therapy. The recommended dosage is 10 ml
                                   (125 mg of elemental iron) administered intravenously during the
                                   dialysis session. Recipients may continue to require therapy with
                                   sodium ferric gluconate complex in sucrose at the lowest dose
                                   necessary to maintain target levels of hemoglobin. Ferrlecit may be
                                   used as an alternative to oral iron therapy.



Ferumoxytol (Feraheme)             Ferumoxytol is used for the treatment of iron deficiency anemia in
                                   patients 18 years of age and older with chronic kidney disease.


Dosage                             The maximum dosage is 510 mg




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Required Codes                     Claims for both Q0138 and Q0139 require two ICD-9-CM codes as
                                   follows:

                                   Q0138 requires one ICD-9-CM code from each box:

                                     First ICD-9-CM             Second ICD-9-CM
                                     Code                       Code
                                     280.0                      585.1
                                     280.1                      585.2
                                     280.9                      585.3
                                                                585.4
                                                                585.5

                                   Q0139 requires one ICD-9-CM code from each box:

                                    First ICD-9-CM                Second ICD-9-
                                    Code                          CM Code
                                    280.0                         585.6
                                    280.1
                                    280.9



Billing                            The following HCPCS codes are used to bill ferumoxytol:
                                       HCPCS
                                       Code               Description
                                       Q0138              Ferumoxytol (Feraheme), Non ESRD, 1 mg
                                                          One unit = 1 mg
                                                          Treatment of iron deficiency anemia in adults
                                                          without chronic kidney disease.

                                       Q0139              Ferumoxytol (Feraheme), ESRD, 1 mg
                                                          One unit = 1 mg
                                                          Treatment of iron deficiency anemia in adults
                                                          with chronic kidney disease.

                                   Codes Q0138 and Q0139 cannot be reported on the same claim.
                                   Claims submitted with only one ICD-9-CM code will be denied.

                                   Claims submitted with either code Q0138 and Q0139 must include the
                                   statement “the patient has failed oral iron therapy and/or is intolerant of
                                   oral iron therapy” in order to be reimbursable. The statement should
                                   be written in the Remarks field (Box 80 on the UB-04) or in the
                                   Reserved for Local Use field (Box 19 on the CMS-1500).




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                            ®
Filgrastim (Neupogen )             Filgrastim is a Medi-Cal benefit when used for patients with severe
                                   neutropenia.


Dosage                             The specific dosage of filgrastim is variable depending on which
                                   condition or disease is being treated.
                                   When billing HCPCS codes J1440 or J1441 for more than 1,200 mcg,
                                   providers must document in the Remarks field (Box 80 on the UB-04)
                                   or the Reserved for Local Use field (Box 19 on the CMS-1500) that the
                                   patient weighs more than 100 kg.


Required Codes                     Filgrastim is reimbursable only with one of the following ICD-9-CM
                                   codes:
                                     205.00                   288.50
                                     205.20                   V07.8
                                     205.30                   V42.81
                                     205.80                   V58.11
                                     205.90                   V66.2
                                     238.72 – 238.76
                                     288.00 – 288.09



Billing                            The following HCPCS codes are used to bill filgrastim:
                                       HCPCS
                                       Code             Description
                                       J1440            Injection, filgrastim (G-CSF), 300 mcg
                                                        One (1) unit = 300 mcg
                                       J1441            Injection, filgrastim (G-CSF), 480 mcg
                                                        One (1) unit = 480 mcg




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                          ®
Fomepizole (Antizol )              Fomepizole, 15 mg, is billed with HCPCS injection code J1451.
                                   Reimbursement is allowed up to a maximum of 140 units.



Fosaprepitant (Emend)             Fosaprepitant injection, 1 mg (HCPCS code J1453) has a maximum
                                   daily dosage of 150 mg. It is reimbursable when administered in
                                   combination with other antiemetic agents and is indicated for the
                                   following:

                                        Prevention of acute and delayed nausea and vomiting
                                         associated with initial and repeat courses of highly emetogenic
                                         cancer chemotherapy, including high-dose cisplatin
                                        Prevention of nausea and vomiting associated with initial and
                                         repeat courses of moderately emetogenic cancer
                                         chemotherapy


Galsulfase (Naglazyme)             For detailed billing policy information about galsulfase, refer to the
                                   “Enzyme Replacement Drugs” topic in this manual section.

                         ®
Goserelin (Zoladex )               Goserelin is reimbursable for the treatment of endometriosis,
                                   advanced carcinoma of the prostate, and for the palliative use in
                                   women with advanced breast cancer.

                                   Goserelin 3.6 mg (HCPCS code X7060) may be reimbursed once a
                                   month when billed in conjunction with one of the following ICD-9-CM
                                   diagnosis codes: 174.0 – 174.9, 185 or 617.0 – 617.9.

                                   Goserelin 10.8 mg (HCPCS code X7061) may be reimbursed once in
                                   80 days (for the same recipient, any provider) when billed in
                                   conjunction with one of the following ICD-9-CM codes: 174.0 – 174.9
                                   or 185.




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Granisetron                        Granisetron is a selective 5-hydroxytryptamine3 (5-HT3) receptor
                                   antagonist with little or no affinity for other serotonin receptors.


Indications                        Granisetron injection is indicated for:

                                        The prevention of nausea and/or vomiting associated with
                                         initial and repeat courses of emetogenic cancer therapy.
                                        The prevention and treatment of postoperative nausea and
                                         vomiting in adults. As with other antiemetics, routine
                                         prophylaxis is not recommended in patients in whom there is
                                         little expectation that nausea and/or vomiting will occur
                                         postoperatively. In patients where nausea and/or vomiting must
                                         be avoided during the postoperative period granisetron injection
                                         is recommended even where the incidence of postoperative
                                         nausea and/or vomiting is low.


Dosage                             For the prevention of chemotherapy-induced nausea and vomiting,
                                   the recommended dosage for granisetron injection is 10 mcg/kg
                                   administered intravenously within 30 minutes before initiation of
                                   chemotherapy, and only on the day(s) chemotherapy is given. Medical
                                   justification is required when the dosage exceeds 1,400 mcg.
                                   For the prevention of postoperative nausea and vomiting, the
                                   recommended dosage is 1,000 mcg of granisetron, undiluted,
                                   administered intravenously over 30 seconds, before induction of
                                   anesthesia or immediately before reversal of anesthesia. The
                                   recommended dosage for the treatment of nausea and/or vomiting
                                   after surgery is 1,000 mcg of granisetron undiluted, administered
                                   intravenously over 30 seconds.


Billing                            HCPCS code J1626 (injection, granisetron HCl, 100 mcg)



Growth Hormone                     For information about the use of growth hormone injections for
Injections                         HIV-Associated wasting, see “Somatropin (Serostim) for
                                   HIV-Associated Wasting” in the Injections: Drugs M–Z Policy
                                   section in this manual.




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                          ®
Hemin (Panhematin )                    Hemin, 1 mg (HCPCS code J1640), is reimbursable for females
                                       10 years of age or older. It may be reimbursed up to a maximum of
                                       602 mg.



Histrelin Acetate                      Histrelin acetate, 10 mcg, (HCPCS injection code J1675) is
                                       reimbursable with authorization, for individuals with precocious
                                       puberty. Claims must be billed “By Report” and shall include an
                                       invoice for the kit.



Histrelin Acetate                      For information regarding histrelin implant, 50 mg (HCPCS code
           ®
(Supprelin LA)                         J9226, Supprelin LA), see the Non-Injectable Drugs section in the
                                       appropriate Part 2 manual.



                                   ®
Histrelin Implant (Vantas )            For information regarding histrelin implant, 50 mg, (HCPCS code
                                       J9225), see the Non-Injectable Drugs section in the appropriate
                                       Part 2 manual.



Human Fibrinogen Concentrate Human fibrinogen concentrate is used in treatment of acute bleeding
(RiaSTAP)                    episodes in persons with congenital fibrinogen deficiency, including
                             afibrinogenemia and hypofibrinogenemia.


Dosage                                 The usual maximum dosage is 7,000 mg (quantity of 70). Claims
                                       billed for greater quantities require documentation that patient’s weight
                                       exceeds 100 kg.


Required Codes                         Restricted to ICD-9-CM diagnosis code 286.3.


Billing                                HCPCS code J1680 (injection, human fibrinogen concentrate,
                                       100 mg)
                                       One unit = 100 mg




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Hyaluronan (Orthovisc)             High molecular weight hyaluronan (Orthovisc) for intra-articular
High Molecular Weight              injection is reimbursable for treatment of the knees. Authorization is
                                   required and documentation must be submitted with the TAR that
                                   satisfies all of the following conditions:
                                        Painful osteoarthritis of one or both knees
                                        Inadequate response to conservative nonpharmacologic
                                         therapy
                                        Inadequate response to analgesics (for example,
                                         acetaminophen) and non-steroidal anti-inflammatory drugs


Dosage                             The usual dose is 2 ml of high molecular weight hyaluronan
                                   (Orthovisc) into the affected knee at weekly intervals for three or four
                                   weeks for a total of three or four injections per affected knee.


Billing                            HCPCS code J7324 (hyaluranon or derivative, Orthovisc, for
                                   intra-articular injection, per dose)



Hylan G-F 20                       Hylan G-F 20 (Synvisc or Synvisc-One) for intra-articular injection is
(Synvisc or Synvisc-One)           reimbursable for treatment of the knees. Authorization is required and
                                   documentation must be submitted with the TAR that satisfies all of the
                                   following conditions:
                                        Painful osteoarthritis of one or both knees
                                        Inadequate response to conservative nonpharmacologic
                                         therapy
                                        Inadequate response to analgesics (for example,
                                         acetaminophen) and non-steroidal anti-inflammatory drugs
                                   The TAR should state which form of hylan G-F 20 the patient will
                                   receive, either Synvisc or Synvisc-One.

Dosage                             Hylan G-F 20 (Synvisc): The usual dose is 16 mg into the affected
                                   knee at weekly intervals for three weeks for a total of three injections
                                   per affected knee.

                                   Hylan G-F 20 (Synvisc-One): The usual dose is 48 mg into the
                                   affected knee. Synvisc-One combines three doses of Synvisc into a
                                   single syringe.

                                   Providers may administer more than 48 units of Hylan G-F 20
                                   (Synvisc-One) per day if bilateral knee injections are needed on the
                                   same day.




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Billing                            HCPCS code J7325 Hyaluranon or derivative, Synvisc or
                                   Synvisc-One, for intra-articular injection, 1 mg

                                   Code J7325 is used for billing either Synvisc or Synvisc-One.

                                   When billing for Synvisc or Synvisc-One, one unit is equivalent to
                                   1 mg.



                           ™
Ibandronate (Boniva )              Ibandronate sodium, 1 mg (HCPCS J1740) is reimbursable
                                   for the treatment of women with post-menopausal osteoporosis.


Dosage                             Dosing frequency is 3 mg every three months administered
                                   intravenously over 15 – 30 seconds by a health care provider.
                                   Ibandronate is contraindicated in patients with hypocalcemia or those
                                   who have a known hypersensitivity to ibandronate sodium.


Required Codes                     Claims must be billed with ICD-9-CM diagnosis code 733.01.


Billing                            Providers must submit the following documentation in the Remarks
                                   field (Box 80)/Reserved for Local Use field (Box 19) on the claim or on
                                   an attachment:
                                        A diagnostic T score of -2.5 or more in women who have
                                         documented difficulty with the oral bisphosphonates dosing
                                         requirement, which includes an inability to sit upright for 30 to 60
                                         minutes and/or difficulty in swallowing a pill; or,
                                        A diagnostic T score of -2.5 or more in women with documented
                                         esophagitis, gastritis, gastric or esophageal ulcers which
                                         prohibit the use of oral bisphosphonates.



Idursulfase (Eleprase)             For detailed billing policy information about idursulfase, refer to the
                                   “Enzyme Replacement Drugs” topic in this manual section.




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Imiglucerase (Cerezyme)            For detailed billing policy information about imiglucerase, refer to the
                                   “Enzyme Replacement Drugs” topic in this manual section.



Immune Serum                       Outpatient use of immune serum globulin I.V., 1 gram (CPT-4 code
Globulin I.V.                      90283) is a covered benefit subject to authorization for several
                                   conditions and for similar disorders which have documented evidence
                                   of improvement with the use of immune serum globulin I.V., 1 gram:

                                        Primary Immune Deficiency
                                          –   X-linked Hypogammaglobulinemia
                                          –   Common Variable Immune Deficiency
                                          –   Severe Combined Immune Deficiency
                                          –   Ataxia-telangiectasia
                                          –   Wiscott-Aldrich syndrome
                                          –   Children unable to form specific antibody on immunization
                                        Secondary Immune Deficiency
                                          – Chronic Lymphocytic Leukemia (CLL)
                                        Transplant recipients at risk for cytomegalovirus infection
                                        Autoimmune Mediated Disease
                                          – Kawasaki Disease
                                          – Idiopathic Thrombocytopenic Purpura, Acute and Chronic
                                            (ITP)
                                          – Coagulopathy due to inhibitors of Factor VIII
                                          – Dermatomyositis (DM)
                                          – Guillain-Barre Syndrome (GBS)
                                          – Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)
                                        Human Immunodeficiency Virus (HIV) infected children who
                                         meet the following criteria:
                                          – Evidence of humoral immune defects; including
                                            ◊ Hypogammaglobulinemia; or
                                            ◊ Lack of antibody response after one or more appropriately
                                              administered immunizations; or

                                          – Significant recurrent infections despite appropriate
                                            antimicrobial therapy; and who
                                            ◊ Are not able to take antibiotic prophylaxis or who have
                                               failed antibiotic prophylaxis; or
                                            ◊ Have had two or more episodes of septicemia with an
                                               encapsulated organism; or
                                            ◊ Have had or currently have a significant infection by an
                                               opportunistic organism.




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Treatment Authorization            TARs must be submitted to the local Medi-Cal field office with a
Request                            laboratory report showing either of the following:
                                        Immune globulin level of less than 300 mg/dL for conditions with
                                         primary immune globulin deficiency; or
                                        Documentation supporting the diagnosis of a disorder
                                         ameliorated by the use of immune serum globulin I.V., along
                                         with any previous treatment regimens and their efficacies and a
                                         new treatment plan.

                                   Approved TARs will authorize administration of a specific number of
                                   grams, shown in the Quantity column.


Outpatient Immune                  When billing for outpatient immune serum globulin I.V., use CPT-4
Serum Globulin I.V.                code 90283, regardless of the manufacturer, and enter the number of
Billing Procedures                 grams used in the Service Units/Days or Units box of the claim form.
                                   The number of milliliters of fluid should not be entered.


Intramuscular                      Providers billing for intramuscular immunoglobulin (IMIG) must use
Immunoglobulin (IMIG)              CPT-4 code 90281 (immune serum globulin, human, for IM use).



                           ®
Infliximab (Remicade )             Infliximab may be reimbursed when used for:
                                        Crohn’s disease:
                                          For reduction in the signs and symptoms of Crohn’s disease
                                           in recipients with moderately to severely active Crohn’s
                                           disease who have had an inadequate response to
                                           conventional therapy.
                                            For reduction in the number of draining enterocutaneous
                                             fistulae in recipients with fistulizing Crohn’s disease.
                                        Rheumatoid arthritis:
                                          When used in combination with methotrexate, for the
                                           reduction in signs and symptoms of rheumatoid arthritis in
                                           recipients who have had an inadequate response to
                                           methotrexate, or who are refractory to other
                                           disease-modifying anti-rheumatic drugs. If the recipient is
                                           intolerant to methotrexate, infliximab must be used in
                                           conjunction with another disease-modifying agent.
                                        Refractory ankylosing spondylitis.
                                        Destructive psoriatic arthropathy.
                                        Active ulcerative colitis that has had an inadequate response to
                                         conventional therapy.
                                        Plaque psoriasis that covers 10 percent or more of the patient’s
                                         body surface area.


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Dosage                             For treatment of moderate to severe Crohn’s disease, the
                                   recommended dose of infliximab is an initial 5 mg/kg given as an
                                   intravenous infusion followed by additional 5 mg/kg doses given at two
                                   and six weeks, then every eight weeks thereafter. The dosage may be
                                   increased to 10 mg/kg for patients who have an incomplete response
                                   to the 5 mg/kg dose. If patients do not respond to the increased
                                   dosage after 14 weeks, providers should consider discontinuing
                                   treatment with infliximab.

                                   For treatment of fistulizing Crohn’s disease, the recommended dose of
                                   infliximab is an initial dose of 5 mg/kg given as an intravenous infusion
                                   followed by additional 5 mg/kg doses given at two and six weeks after
                                   the initial dose.

                                   For treatment of rheumatoid arthritis, the recommended dose of
                                   infliximab is an initial 3 mg/kg given as an intravenous infusion
                                   followed by additional 3 mg/kg doses given at two and six weeks,
                                   then every eight weeks thereafter. The dosage may be adjusted to
                                   10 mg/kg every eight weeks or 5 mg/kg every four weeks for patients
                                   who have an incomplete response to the 3 mg/kg dose. Infliximab
                                   should be given in combination with methotrexate or another
                                   disease-modifying agent.


TAR Required                       Infliximab treatment requires a TAR. The patient’s condition must be
                                   entered in the Medical Justification area of the TAR. When requesting
                                   authorization for plaque psoriasis, documentation stating that the
                                   plaque psoriasis covers 10 percent or more of the patient’s body
                                   surface area must be on or attached to the TAR.


Billing                            Infliximab, 10 mg (HCPCS code J1745)




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Lacosamide (Vimpat)                    Lacosamide injection is indicated for intravenous use as adjunctive
                                       therapy in the treatment of partial-onset seizures in patients with
                                       epilepsy aged 17 years and older when oral administration is
                                       temporarily not feasible. The precise mechanism by which lacosamide
                                       exerts its antiepileptic effects in humans remains to be fully elucidated.


Dosage                                 The initial dose should be 100 mg intravenously in two divided doses
                                       and can be increased at weekly intervals by 100 mg per day in two
                                       divided doses up to the recommended maintenance dose of 200 to
                                       400 mg per day.

                                       The maximum daily dose is 400 mg.


Diagnosis Restrictions                 Restricted to ICD-9-CM diagnosis codes 345.50 – 345.51.


Billing                                HCPCS code C9254 (injection, lacosamide, 1 mg)



                               ®
Lanreotide (Somatuline )               Lanreotide acetate, 1 mg (HCPCS code J1930) is reimbursable for the
                                       treatment of acromegaly and gigantism. Claims must be billed with
                                       ICD-9-CM diagnosis code 253.0. The maximum daily dosage is 120
                                       mg. Claims billed for quantities exceeding the daily limitation require
                                       appropriate documentation for payment.



Laronidase (Aldurazyme)                For detailed billing policy information about laronidase, refer to the
                                       “Enzyme Replacement Drugs” topic in this manual section.



                                   ®
Leuprolide (Lupron Depot )             Leuprolide acetate injections are reimbursable when billed in
                                       conjunction with an appropriate ICD-9-CM diagnosis code. Leuprolide
                                       acetate is used to suppress sex hormone production and is available
                                       for both adult and pediatric care.

                                       Refer to “Leuprolide acetate” in the Chemotherapy: Drugs E-O Policy
                                       section of the appropriate Part 2 manual for information on the use of
                                       leuprolide in malignant disease.


Dosage                                 The various dosing schedules are based upon the disease being
                                       treated. The usual dose is between 3.75 and 45 mg and is
                                       administered as frequently as monthly and as infrequently as every six
                                       months depending on which drug formulation is administered.




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Required Codes                     Leuprolide acetate is reimbursable at a frequency of up to once every
                                   30 days when billed with any of the following ICD-9-CM codes:
                                       218.0 – 218.9
                                       259.1
                                       617.0 – 617.


Billing                            The following HCPCS codes should be billed in conjunction with the
                                   appropriate ICD-9-CM diagnosis code.
                                      J1950           Injection, leuprolide acetate (for depot
                                                      suspension), per 3.75 mg
                                      J9217           Injection, leuprolide acetate (for depot
                                                      suspension), per 7.5 mg (Lupron or Eligard may
                                                      be used for the 7.5 mg dose)



                              ®
Levetiracetam (Keppra )            Levetiracetam, 10 mg (HCPCS code J1953) has a maximum daily
                                   dose of 3,000 mg. Claims billed for quantities exceeding the daily
                                   limitation require appropriate documentation for payment.



Levonorgestrel Implant             Refer to the Family Planning section in the appropriate Part 2
         ®
(Norplant II)                      manual for billing instructions for levonorgestrel contraceptive implant
                                   systems (HCPCS code J7306).




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Lacosamide (Vimpat)                    Lacosamide injection is indicated for intravenous use as adjunctive
                                       therapy in the treatment of partial-onset seizures in patients with
                                       epilepsy aged 17 years and older when oral administration is
                                       temporarily not feasible. The precise mechanism by which lacosamide
                                       exerts its antiepileptic effects in humans remains to be fully elucidated.


Dosage                                 The initial dose should be 100 mg intravenously in two divided doses
                                       and can be increased at weekly intervals by 100 mg per day in two
                                       divided doses up to the recommended maintenance dose of 200 to
                                       400 mg per day.

                                       The maximum daily dose is 400 mg.


Diagnosis Restrictions                 Restricted to ICD-9-CM diagnosis codes 345.50 – 345.51.


Billing                                HCPCS code C9254 (injection, lacosamide, 1 mg)



                               ®
Lanreotide (Somatuline )               Lanreotide acetate, 1 mg (HCPCS code J1930) is reimbursable for the
                                       treatment of acromegaly and gigantism. Claims must be billed with
                                       ICD-9-CM diagnosis code 253.0. The maximum daily dosage is 120
                                       mg. Claims billed for quantities exceeding the daily limitation require
                                       appropriate documentation for payment.



Laronidase (Aldurazyme)                For detailed billing policy information about laronidase, refer to the
                                       “Enzyme Replacement Drugs” topic in this manual section.



                                   ®
Leuprolide (Lupron Depot )             Leuprolide acetate injections are reimbursable when billed in
                                       conjunction with an appropriate ICD-9-CM diagnosis code. Leuprolide
                                       acetate is used to suppress sex hormone production and is available
                                       for both adult and pediatric care.

                                       Refer to “Leuprolide acetate” in the Chemotherapy: Drugs E-O Policy
                                       section of the appropriate Part 2 manual for information on the use of
                                       leuprolide in malignant disease.


Dosage                                 The various dosing schedules are based upon the disease being
                                       treated. The usual dose is between 3.75 and 45 mg and is
                                       administered as frequently as monthly and as infrequently as every six
                                       months depending on which drug formulation is administered.




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Required Codes                     Leuprolide acetate is reimbursable at a frequency of up to once every
                                   30 days when billed with any of the following ICD-9-CM codes:
                                       218.0 – 218.9
                                       259.1
                                       617.0 – 617.


Billing                            The following HCPCS codes should be billed in conjunction with the
                                   appropriate ICD-9-CM diagnosis code.

                                       J1950            Injection, leuprolide acetate (for depot
                                                        suspension), per 3.75 mg
                                       J9217            Injection, leuprolide acetate (for depot
                                                        suspension), per 7.5 mg (Lupron or Eligard may
                                                        be used for the 7.5 mg dose)



                              ®
Levetiracetam (Keppra )            Levetiracetam, 10 mg (HCPCS code J1953) has a maximum daily
                                   dose of 3,000 mg. Claims billed for quantities exceeding the daily
                                   limitation require appropriate documentation for payment.



Levonorgestrel Implant             Refer to the Family Planning section in the appropriate Part 2
         ®
(Norplant II)                      manual for billing instructions for levonorgestrel contraceptive implant
                                   systems (HCPCS code J7306).




2 – Injections: Drugs A-L Policy
                                                                                                  August 2010

				
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